ASSESSMENT NURSING PLANNING NURSING RATIONALE EVALUATION

DIAGNOSIS INTERVENTIONS
Subjective: Fear and Ineffective Short-term goals: Independent: Goal met
Coping Related to
“I can’t stand the idea of Personal Vulnerability After 1 hour of nursing  Provide factual  Factual information serves Short-term goals:
having one of my Secondary to interventions, the information concerning as a foundation for Maria to
breasts cut off; I don’t patient will verbalize After 1 hour of nursing
Mastectomy. the diagnosis, treatment, explore feelings and
know how I’m going to sense of control and interventions, the
and prognosis. alternative coping strategies.
be able to even look at report decrease in patient has verbalized
Stressed clients often
myself” as verbalized by negative feelings. sense of control and
misunderstand facts and
Maria. reported decrease in
require frequent clarification
negative feelings.
so that appropriate
Long-term goals: conclusions can be drawn.
Objective: Having valid information
After 2 hours of helps relieve stress. Long-term goals: After
 BP: 140/ 80 nursing intervention, Dependent: 8 hours of nursing
 T: 36.8 degrees the patient will Identify  Alteration in body image intervention, the patient
Centigrade effective and  Appraise Mary’s may be a major issue for has Identified effective
 PR: 89 BPM ineffective coping adjustment to changes in Ruby and should be and ineffective coping
 RR: 25 BPM patterns. body image. explored to facilitate patterns.
 Pale therapeutic intervention.
 Shallow breathing Coping strategies often
 Sweating change with a reappraisal of
the situation.
 Hands shaking  Arrange situations that  Enhances a sense of control,
encourage her autonomy. personal achievement, and
Give her as many self-esteem.
opportunities as possible
to make decisions/choices
for herself.
 Explore with her previous  Present and past coping
methods of dealing with status assists both Mary and
life problems. her husband in capitalizing
on successful methods,
identifying ineffective
strategies, and developing
new skills more appropriate
to the present situation. Also
determines risk for inflicting
self-harm.
 Open, nonthreatening
 Encourage verbalization discussions facilitate the
of feelings, perceptions, identification of causative
and fears. and contributing factors.
 Assists Mary to develop
 Encourage Mary to appropriate strategies for
identify her own coping based on personal
strengths and abilities. strengths and previous
experiences. Improves self-
concept and sense of ability
to manage stress.
 Individuals experiencing
 Encourage Mary to stress may have unrealistic
realistically describe perceptions or reality
changes in her role. distortions. Helping Mary
clearly describe her role
 Foster constructive would be beneficial in
outlets for anger and developing realistic goals for
hostility role achievement.
 Assessing family interaction
 Observe the degree of serves as a basis for
family support. identifying Mary’s support
systems or lack thereof.

 Although adequate support

 Determine barriers to
systems may be available,
using support systems. Mary may not be using them
or may be using them
ineffectively.
 Supporting Mary in
 Involve husband, family, acknowledging changes in
and friends in the care her appearance conveys
and planning. acceptance and provides a
foundation for her to begin
to adjust.
 Family and friends are often
 Discuss with concerned willing but unsure how to
others how they can help help. Identifying specific
strategies such as praise and
encouragement during
rehabilitation and healing
will promote acceptance of
change
Collaborative:  Community support is
beneficial in helping to meet
 Refer Mary to a
unresolved needs,
community-based breast
cancer support group. decreasing feelings of social
isolation, and facilitating a
positive self-image.